The Choices in Care Study was conducted by the New York State Department of Health's AIDS Institute with research staff from the Memorial Sloan-Kettering Cancer Center. The study began in 2003 with the inception of HIV Special Needs Plans (SNPs), a managed care model designed to address the care needs of people living with HIV/AIDS (PLWHAs). The purpose of the study was to evaluate the effectiveness of the HIV SNP in comparison with services received under the Medicaid fee-for-service (FFS) system by examining respondents' self-reported perceptions of care. As of July 2008, 3,255 individuals (both HIV-infected persons and their uninfected children) were enrolled in the three operating HIV SNPs.

Methodology

The study involved two groups of HIV-positive Medicaid recipients. The first group was comprised of persons newly-enrolled in one of the three HIV SNPs and who were recruited within 45-90 days of their HIV SNP enrollment. The second group was comprised of persons receiving care under the FFS model and who responded to flyers recruiting for the study that were posted at Designated AIDS Centers, community-based organizations, and AIDS adult day health care programs. Study participants were followed for a year through a series of five interviews at three-month intervals, including a baseline interview on recruitment into the study. The interviews focused on respondents' self-reported health history and status, utilization of services, adherence to treatment, risk behavior, quality of life, and their perceptions of the care received – whether and to what extent their concerns were resolved, problems with the care they received, and satisfaction with the care or services they received - either as an HIV SNP enrollee or while receiving care through the FFS system. The experiences in care of both sets of study respondents over the 12-month period were examined over several domains. Of the 628 individuals completing a baseline interview, 470 individuals or 74.8% completed all five interviews.

Study Findings

Key findings and initial conclusions from the analysis of the baseline interviews and the first and second three-month interviews are summarized below.

Continuity and Coordination of Care

HIV SNP enrollees reported fewer interruptions in their relationships with providers than the FFS recipients in the study.

HIV SNP enrollees reported being more likely to receive referrals from their primary care physician or case managers than FFS respondents.

HIV SNP enrollees mentioned more new medical specialists available to them, while FFS recipients in the study mentioned more new primary care providers (PCPs). HIV SNP enrollees were more likely than FFS recipients to stay with their PCPs and to expand their network of specialists.

Barriers to Care

HIV SNP enrollees who were actively seeking help reported fewer barriers than their FFS counterparts.

Communication with Providers

HIV SNP enrollees reported fewer problems in communicating with their providers than FFS respondents. HIV SNP enrollees were also significantly less likely to report that providers failed to address their problems or treated them disrespectfully.

Among those patients who reported recent medical problems, FFS recipients in the study were more likely to say that medical instructions they had received were unclear than those enrolled in an HIV SNP.

Satisfaction

Although satisfaction with care received was found to be very high for both HIV SNP and FFS groups, the study found that HIV SNP enrollees concerned with obtaining specialty or inpatient care were significantly more satisfied with their providers than the FFS respondents.

Problem Resolution

HIV SNP study participants who were actively engaged in care had more favorable outcomes regarding the resolution of problems than FFS respondents.

Medical Symptoms

Among study respondents who reported medical symptoms at baseline, HIV SNP enrollees reported fewer symptoms at the time of the six-month interview than those in FFS. This difference is more pronounced among those with emergent medical problems.

Sexual Risk Behavior

HIV SNP enrollees who were receiving services reported a decrease in unprotected sex with HIV-negative persons or those with unknown HIV status; FFS respondents reported an increase in unprotected sex with HIV-negative persons or those with unknown HIV status at the time of the six-month follow-up.

Tobacco Use

Among respondents who were smoking at baseline, HIV SNP enrollees were less likely to still be smoking by the time of six-month interview than their FFS counterparts. This effect is even more prominent when focusing on those who had ever smoked.